California Department of Aging Planning for the Baby ... · PDF fileCalifornia Department of Aging Planning for the Baby Boomers Report: Integration of Service Systems Introduction

California Department of Aging

Planning for the Baby Boomers Report:

Integration of Service Systems Introduction In its guidance for developing the 2005-2009 Area Plan on Aging, the California Department of Aging (CDA) asked the 33 Area Agencies on Aging (AAAs) to address several questions that probe their planning for the sizeable growth of California’s aging boomers (individuals born between 1946 and 1964) who are soon to become eligible for Medicare, Social Security, and home and community based programs providing information and assistance, opportunities for community involvement, family caregiver support, and supportive services to older adults and adults with disabilities. The questions the AAAs were asked to respond to were posed in Planning for an Aging California Population: Preparing for the “Aging Baby Boomers.” This report, released in May 2004, summarized the Assembly Committee on Aging and Long Term Care’s California Strategic Plan on Aging Advisory Committee findings and recommendations. The AAAs responding to these planning questions frequently note that they are already providing services to aging boomers through various programs including Linkages and the Family Caregiver Support Program. Some AAAs also administer Adult Protective Services, In-Home Supportive Services, and may fund other local transportation, housing, and/or nutrition programs that that serve Boomers with disabilities, who are not yet eligible for Medicare, Social Security and/or federal Older Americans Act programs. Many of the references the AAAs draw upon in their responses are based on their experience in providing services to these clients and the service preferences and expectations expressed by these clients. It is not too early to begin preparing for the impact of the sizeable Boomer cohort, but it is also important to note that the oldest of this age group will not reach age 75 until 2020. As noted in Before the Boom: Trends in Long-Term Supportive Services for Older Americans with Disabilities AARP (October 2002) “boomer driven demand for long-term supportive services is not likely to increase substantially for roughly 20 years or more”. While drawing on the experiences, expectations, and needs of the current cohort of Boomer clients with disabilities is important to incorporate in the AAA planning process, much is still unknown as to how their experience and skills in “navigating the system” will differ from those of Boomers 30 years from now, who may experience a disability for the first time. What we do know is there will be a growing diversity in the socio-demographic characteristics of the aging Boomer cohort and a greater diversity in their needs and preferences. However, there are values that span generations and age

Planning for the Baby Boomers Report: Integration of Service Systems

Area Plan Appendix XII September 2006

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cohorts. By implementing changes that address our growing diversity, increase consumer choice, assure service quality, and support independent living, all Californians in need of supportive services today and tomorrow, will benefit. Questions Asked The questions framed in the Planning for an Aging California Population: Preparing for the “Aging Baby Boomers” included:

1. How can we best integrate service systems for the elderly and adults with disabilities while, at the same time, acknowledging and responding to differences between these population groups?

2. Who are the key stakeholders whose commitment and partnership are

essential?

3. How can we assure we help empower individuals to remain as independent and engaged as possible for as long as possible?

4. How can the arrangement of services be delivered to the consumer in a

seamless, coordinated manner, regardless of program administration and jurisdiction?

5. What administrative hurdles and barriers to change need to be overcome at

both the state and county/local level?

6. How do we provide a leadership and advocacy role in the development of service system standards that are uniform and not dependent upon income?

7. How do we assure quality standards are maintained or developed across

services regardless of the funding source and/or the service provider? Question #1 How can we best integrate service systems for the elderly and adults with disabilities while, at the same time, acknowledging and responding to differences between these populations groups? Philosophy We should not consider these as two separate groups but as individuals with more than one need. (PSA1 3) Despite the fact that services for the elderly and for adults with disabilities often respond to similar needs in terms of consumer’s functional needs, our community

1 Planning and Service Area. There are 33 Planning and Service Areas in California. Each Planning and Service Area contains an Area Agency on Aging that is responsible for coordinating services for the elderly and disabled under the Older Americans Act and the Older Californians Act.



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has found that the public and private service providers serving these constituencies have not always communicated as well as they could. (PSA 6) Having provided services to both populations, we acknowledge that the two have different preferences in delivery of service and accommodate those preferences accordingly. (PSA 1)

Our customers are not concerned with the name or title of the program, only the outcome. (PSA 3) Baby Boomers and adults with disabilities tend to want greater control over their decision-making than do many of our older seniors. They want to be informed about their options and to make their own choices. Aging and Adult Services’ philosophy of client-centered services supports the role of the client as decision-maker. Last, but not least, we must examine the way we have traditionally delivered services and make adjustments that will allow us to serve our diverse community of seniors and adults with disabilities. Programs that have traditionally served large numbers of seniors may not be needed or readily accepted by our newer senior generation. We know that Baby Boomers generally do not identify with the term “senior” and may not be attracted to programs marketed to “seniors”. (PSA 8) The Los Angeles City Department of Aging has also been exploring the issues and needs of developmentally disabled adults who are now aging in larger numbers. (PSA 25) Examples of Service Integration Resource Directory Our resource directory has been inclusive of services and distributed to both populations for over three years. This directory is available in a variety of formats including print, web version and brail. (PSA 1) Grants In 2004, the AAA2 received an Aging and Disability Resource Center grant from Administration on Aging via the California Department of Aging for its Del Norte InfoCenter, a single point of entry Information and Assistance program established in 1998. The AAA’s Caregiver Support Project began in 2000 to provide caregiver training, support and registry for caregivers to seniors and adults with disabilities. (PSA 1) Volunteers The AAA’s all age Volunteer Center has for the past several years had a focus on engaging adults with disabilities into service. (PSA 1) Outside Resources/Collaboration 2 AAA is the Area Agency on Aging



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The local Independent Living Center executive director is a member of the AAA Advisory Council. (PSA 1) Coordinating Bodies or Councils or Active Cross Communication The Mayor of San Francisco has convened a Long Term Care Coordinating Council, which: (1) provides policy guidance on all home, community-based, and institutional long term care issues; and (2) oversees the implementation of the Living With Dignity Strategic Plan to make improvements in San Francisco’s community-based long term care and supportive services system. The Coordinating Council has implementation workgroups and presents periodic reports and updates on implementation progress to the Mayor. The Department of Aging and Adult Services (DAAS) provides ongoing staff support; facilitates meetings; and performs and presents research. Anne Hinton, the executive director of DAAS, is also a member of the Coordinating Council. (PSA 6) Aging and Adult Services has three formal advisory bodies—the Commission on Aging, Commission on Disabilities and the Public Authority Advisory Committee. Each commission also has committees that focus on specific issue areas and include representatives from community-based organizations, as well as members of the community. The Public Authority Advisory Committee is an 11-member body that meets and confers with the Public Authority in administration of the In-Home Supportive Services (IHSS) Program. The three groups provide an ongoing opportunity for consumers and interested community advocates to influence and participate in the development of public policy. (PSA 8) Adult Services also works with the New Beginning Coalition and a variety of other committees which provide ongoing input regarding the needs and perspectives of seniors and adults with disabilities. (PSA 11) At the AAA, the Executive Director of the Center for Independent Living (CIL)-Fresno serves side-by-side with seniors as an Advisory Council Member. (PSA 14) The City of Los Angeles is fortunate in that it has a Department of Disability that works in close collaboration with the Los Angeles City Department of Aging. For example, the departments have successfully advocated for the funding of Special Populations Coordinator within the City’s Emergency Management Department to serve as liaison among the agencies with a focus on older adults and adults with disabilities. (PSA 25) The AAA has a well-established relationship with the local Disability Resources Agency for Independent Living (DRAIL). One staff member from DRAIL is an active member of our Commission on Aging. (PSA 30) Mariposa library and Senior Centers in the service area are equipped with computers with wireless connections to allow seniors and adults with disabilities in these rural areas access to the internet and vital information otherwise unavailable to them.



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(PSA 12) AAA Resources With our assistance, one of our contractors, the Marin Center for Independent Living, created an online registry of in-home support service workers for the public to search. (PSA 5) We maintain Linkages as a direct service which allows us to broaden awareness and understanding of our services between these population groups in the five county areas. Our Linkages staff coordinates with Disability Resources Agency for Independent Living (DRAIL) providing donated computer equipment, while DRAIL staff provides the computer training to participants based on individual need. (PSA 12) Two key examples of local efforts to improve the integration of service systems for the elderly and adults with disabilities include: (a) the development of a pilot project to provide home-delivered meals to younger adults with disabilities; and (b) the development of “Case Management Connect,” a demonstration project in which a group of 15 case management programs develop a formal organization through which they can collaborate more effectively and coordinate case management services for the diverse clients they serve. (PSA 6) By establishing the Acute and Long Term Care Integration Project (ALTCI) the AAA has been involved for ten years in working to remove barriers to service, reduce duplication, coordinate Community-Based Organization (CBO) services and provide an integrated model of medical and social services. The AAA, as part of the ALTCI work plan, has done extensive data and demographic collection on the needs of both seniors and persons with disabilities. This has been accomplished through community surveys, focus groups and, the AAA Advisory council work groups and committees. The ALTCI project has addressed the needs of both seniors and persons with disabilities individually and collectively. This has been accomplished through a consumer work group made up of lay persons from both the aged and disabilities community. In addition, both of these groups have representation on the ALTCI Task Force and at community forums. (PSA 7) The AAA is planning to expand its integration with In Home Supportive Services to access the population of baby boomers most likely to rely on services for isolated and high risk elders. We are currently reviewing IHSS intake procedures and how to best integrate them in our community based programs. We are also looking to develop community education for those who are currently unaware of their future resource needs. (PSA 9) Requirements



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Ensure that planning is congruent with Olmstead Act3 intentions. (PSA 28) Technology Resources The AAA purchased the database Network of Care, a model Internet based Information and Assistance tool that addresses the care needs of the aged, disabled and is especially suited for their caregivers. Service information is available in Spanish, Mandarin and Cantonese. It has a component entitled “My Record,” a secure place to keep important information about an individual’s health care, and community support services and communications can be shared among family members for whom the primary user grants entry. Users can refer to a library of articles on health issues, a catalogue describing assistive devices and research on the latest legislation. During the last program year, this site received over one million hits and it is fair to assume that a percentage of the traffic was from adult children caregivers encouraging them to examine the situation of a family member, research appropriate resources, and implement a plan of action without ever having to recourse to an intermediary agency like the Council On Aging. (PSA 10) The Los Angeles City Department of Aging produces a television show, “Aging In L.A.” which discusses issues that impact both populations with professionals who are familiar with both populations. (PSA 25) Activities In a rural sparsely populated region like Inyo and Mono Counties, it is important for all service providers to know what other service providers have available. This fosters appropriate referrals, avoidance of duplicate services and the ability to identify gaps in services. This step has been taken in Inyo and Mono Counties as evidenced by Older American’s Month activities May 8, 2006 through June 2, 2006 including service and health fairs in Lone Pine, Bishop and Walker, a history of provider education and communication through the Frail and Elder Task Force, Multi-Disciplinary Teams, service on Advisory Councils’ for IHSS, and other coordination described earlier in the Plan. (PSA 16)

The Medicare-Approved Drug Discount Card Outreach Project is an example of collaborating with agencies on a project designed to reach low-income older adults and people with disabilities. This coordinated effort has been successful in the enrollment and/or education of over a million people. (PSA 25)

3 The New Freedom Initiative (NFI) was announced by President Bush on February 1, 2001, followed by Executive Order 13217 on June 18, 2001. The initiative is a nationwide effort to remove barriers to community living for people of all ages with disabilities and long-term illnesses. This initiative supports states' efforts to meet the goals of the Olmstead v. L.C. Supreme Court decision issued in July 1999 that requires states to administer services, programs, and activities "in the most integrated setting appropriate to the needs of qualified individuals with disabilities." Information from the Centers for Medicare and Medicaid Services website.



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In Sonoma County, Senior Centers are exploring ways to attract younger seniors. Some of their strategies include:

Removal of the name ‘seniors’ from their title and changing to ‘adult community center.’

Integrating more computer and educational programming to complement the activities currently provided such as arts, etc.

Adding more exercise programs with which ‘boomers’ are familiar, e.g., yoga, etc.

Increasing hours to extend beyond 5:00 p.m. (PSA 27)

Research The Solano-Napa Health Fund contracted with consultants to develop a report to identify current and future gaps in services for these ages 45-64, and especially those living at or below 300% of the Federal Poverty Level. Several indicators were identified for which valid and reliable data need to be available on a consistent basis. These include age related data for emergency room and urgent care use, chronic conditions, nutrition, dental, comprehensive mental health data, involuntary detention for mental health-related issues, and more health insurance data to name a few. (PSA 28)

Future Considerations Suggestions It would be helpful to have a media campaign developed throughout the state that provides some uniformity of message to boomers. (PSA 27)

Technology The integration of computer data systems would be ideal to incorporate and duplicate client data and to match client needs with appropriate services. (PSA 2)

The Acute and Long Term Care Integration Project (ALTCI) work plan includes development of a software system to connect consumer medical and social services in one coordinated, integrated care plan. The AAA in conjunction with ALTCI is also involved in looking at new software that provides a comprehensive communication process between the members of the Care Management Team with one another and with all service providers, both medical and social providers. (PSA 7)

Typically, both groups seek immediate access to information and see the Internet as a valuable tool for meeting that expectation. For this reason we have begun to focus on the Internet as a major means to get information about services and issues out to the community. Not only do our two commissions--the Commission on Aging and Commission on Disabilities--maintain their own websites, but Aging and Adult Services has designated a portion of its funding to maintain a comprehensive web-based information system, Network of Care. (PSA 8)



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Information technology can help them manage assets wisely. Online services can deliver food, pharmacy supplies, and laundry. Consumers can access health care information and become a participant in their health care through, for example, remote telemetry, and health web sites. Information technology can even assist older consumers in managing the safety and security of their homes. (PSA 7)

Pioneer Home Health Agency is beginning to use telemedicine in its practice and the Mono and Inyo County Health Departments are using Global Positioning System (GPS) technology for disaster preparedness as described in Appendix XI. The AAA has an Advisory Council representative who is working with the Inyo Mono Advocates for Community Action (IMACA) to develop a local independent living center for the disabled. (PSA 16)

Integrating existing services systems with technology is a focus of the Merced County Area Agency on Aging. One example of this is our purchase of hand held Personal Digital Assistants (PDAs) that provide current information about medications and a print out of up-to-date information about the possible adverse effects of these medications. We will authorize the Health Insurance Counseling and Advocacy Program (HICAP) staff and volunteers access to this software program thereby making available an additional service to clients during HICAP counseling sessions. (PSA 31)

Data We need a comprehensive longitudinal database that will track characteristics, care navigation, needs, and effect of policy and program initiatives for older adults, baby boomer, persons with disabilities. There is a lack of comprehensive projection and trend data for the targeted age groups, particularly the boomers. (PSA 28) Baby Boomer Question # 2 Who are the key stakeholders whose commitment and partnership are essential? Some of the answers identify specific organizations, other categories list types of organizations, businesses, corporations, etc. Colleges/Universities/Educational organizations Humboldt State University Student Disability Center (PSA 1) College of the Redwoods Student Disability Center (PSA 1) Cal Lutheran University (PSA 18) Cal State Channel Islands (PSA 18) Pepperdine University (PSA 18) Osher Learning Institute (PSA 18) Californian Social Work Education Center (CalSWEC) (PSA 33) Social Service Agencies/Programs Dial-a-Ride (PSA 16) Retired Senior Volunteer Programs (PSA 18) Partners In Care (PSA 25)



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Jewish Family Services (PSA 25) Salvation Army (PSA 30) State Agencies California Highway Patrol (PSA 28) Department of Motor Vehicles (PSA 28) Foundations Robert Wood Johnson Foundation (PSA 25) Federal Agencies Naval Base Ventura County (PSA 18) The Centers for Disease Control and Prevention (PSA 25) U.S. Department of Health and Human Services (PSA 25) Associations/Commissions/Councils/Committees/Boards Independent Living Council (PSA 1) Northwest Committee for Employment of People with Disabilities (PSA 1) Long Term Care Coordinating Counsel of San Francisco (PSA 6) Santa Cruz County Regional Transportation Commission (PSA 13) Mono Association for the Handicapped (PSA 16) AARP (PSA 22) San Diego Association of Governments (SANDAG) (PSA 23) Medical Organizations The Health Trust, an agency formed to support health related programs (PSA 10) Central Coast Alliance for Health (PSA 13) Proposition 63 Mental Health (PSA 16) Camarillo Health Care District (PSA 18) WellPoint Health Network (PSA 18) SCAN (PSA 22) CalOptima (PSA 22) Utility Companies GTE (PSA 18) Companies/Corporations/Boards Amgen Corporation (PSA 18) Countrywide Financial (PSA 18) Technicolor Video Services (PSA 18) Harbor Freight Tools (PSA 18) Generic groups or individuals Veterans groups Agricultural business Employers

a) Shopping malls



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Religious organizations Government

a) City and County b) State c) Federal

Health a) Health Department b) Health Clinics c) Medical schools d) Dental schools e) Pharmacy schools

Citizens Groups a) Neighborhood Watch b) Caregivers

Service Providers a) Senior Service Providers b) AAA Contractors c) Transportation providers d) Housing e) Caregiver Resource Centers

Funding Sources a) Foundations Education

a) Community Colleges b) Gerontology departments

Question #3 How can we assure we help empower individuals to remain as independent and engaged as possible for as long as possible? Include consumers in the process of program development, evaluation, and change. (PSA 1) Focus on the strengths people have and help them use those strengths to make connections with the community in a variety of different ways. (PSA 1) Opportunities to engage the older adult population should include opportunities for volunteerism through community involvement. (PSA 3) We worked to create locally a retired persons volunteer registry and matching service called Masters of Marin for volunteers to work with seniors. (PSA 5) Other programs we operate: Healthy Housing, Project Independence, volunteer drivers, and a chronic disease self-management class aim to keep older adults independent as long as possible in their homes. (PSA 5)



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RSVP program has been very pro-active in researching these interests and needs with respect to the Baby Boomer population. RSVP conducted both a literature review focused on aging and civic engagement, as well as a survey of San Francisco residents aged 55 and older to understand key points of engagement for that population in the city. (PSA 6) San Francisco Master of Public Health students, in collaboration with the San Francisco Partnership for Community-Based Care and Support and the San Francisco Senior Center, conducted a separate effort to understand consumer needs by assessing the social and wellness needs of San Francisco residents not currently using senior centers aged 55 – 65 years old. (PSA 6) Through the input of the ALTCI consumer groups, a program that is consumer driven has developed. Consumers have stated they desire an integrated, seamless delivery system of services that emphasize the home and community based components of long term care as opposed to institutional care. (PSA 7) The growing racial/cultural diversity in the senior population requires that the continuum of services be more culturally competent. (PSA 8) Consumers are involved in all phases of the development of the countywide Strategic Plan for Services for Older Adults and Adults with Disabilities. They are encouraged to identify issues, barriers, gaps in service; to share their experiences; to evaluate services; and to recommend solutions and strategies. Consumers are also encouraged to participate on the many committees that address issues of concern/interest to seniors and adults with disabilities. (PSA 8) Traditional volunteer roles may no longer attract the younger senior, who feels he has expertise to offer. (PSA 8) In light of the successful implementation of the Info Van, Council on Aging (COA) is considering expanding the Info Van concept to a mobile geriatric caregiver center. (PSA 10) A second concept under consideration is to approach major corporations and have them install kiosks in their lobbies with the latest and best care giving information supplied by COA. (PSA 10) An emphasis on public hearings is essential for their voice (individuals) to be most effective. (PSA 11) It is important for services and business to keep human faces and voices available for customer interaction. (PSA 13) The FMAAA's vision is to facilitate private development of safe, affordable housing adjacent to the Sierra Resource Campus in which a diverse mix of seniors, disabled adults, and other active adults will thrive in an environment offering multiple



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accommodation options that are tailored to the individual, including independent living and varying levels of assisted living. (PSA 14) Working models are needed in each public service area to educate employers on the advantages and special needs of this workforce. Such a model could create mentoring partnerships between older and younger employees; set up job-sharing with other older workers and/or parents working part-time; implement a van-pool that provides transportation to and from work; offer lunch-time exercise classes, language classes, and book discussion clubs; and offer healthy lunch options and/or snacks in cafeterias and vending machines, where they exist. (PSA 14) A survey is planned for FY06/07 to determine the needs and preferences of the Baby Boomers in PSA 15. (PSA 15) Independence is synonymous with good health. Funding for services and programs that promote health and fitness (such as Title III D) needs to be increased, not cut. Health screenings, fitness activities, activities that exercise the brain, and opportunities for socialization need to be offered and promoted. (PSA 18) Boomers are high tech, Internet savvy, thus, service providers will need to respond accordingly. Many have already begun to respond by providing in-depth information online, surveys, educational programs, etc. (PSA 18) Another vast issue in this county is the number of undocumented people who live here. It has been our experience that on many occasion, efforts of assistance become mixed into a fear of getting in trouble. These issues in particular are still being researched. (PSA 19) Develop a broad menu of flexible services rather than a single facility-based service system of the past. (PSA 20) As written in the “Strategic Plan for An Aging California Population Getting California Ready for the “Baby Boomers”, develop new person-centered care models that empower older adults to better manage their own chronic health conditions. (PSA 20) More health professionals and paraprofessionals with training in gerontology and geriatrics are needed. Work with universities, schools, junior colleges and other educational facilities to develop awareness of this need. (PSA 20) Train existing PSA staff on the changing demographics of our senior population. (PSA 20) Provide objective, accessible and useful information for preparation for healthy aging, retirement, long term care, availability of assistive devices and home modifications through an integration of a traditional (in person) and technological (electronic format) approach. (PSA 31)



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Question #4 How can the arrangement of services be delivered to the consumer in a seamless, coordinated manner, regardless of program administration and jurisdiction? A seamless delivery of services is created through the development of the local workgroups (as described earlier). As the workgroups are developed to consist of local community leaders, a forum is developed which would not only encourage suggestions and coordination possibilities, the forum would also identify unmet needs and gaps in services (through an ongoing process in which each individual service would track and report back to the workgroup) and be empowered to adjust services as needed. (PSA 2) Consider single point of entry/one stop shop clustering of programs. Serve the whole person, not the funding source. (PSA 3) Allow blended funding (i.e., transportation programs) Allow creative Medi-Cal funding waivers Fund “one stop” centers, such as multi-purpose senior centers Use County based AAA integrated sites as models for successful integration

(PSA 32) Coordinate town hall sessions between state and federal agencies, local agencies, and the public and private sectors to improve communication. (PSA 31) The monthly Services to Older Adults Advisory Committee (STOAAC) are attended by representatives from organizations and agencies who are concerned with assisting senior citizens and disabled persons. This kind of networking allows the AAA and other senior services agencies the opportunity to exchange ideas and information toward the end of maintaining the health and well-being of the seniors, caregivers and disabled persons of Stanislaus County. (PSA 30) While seamless service delivery without regard to program administration and jurisdiction is an excellent goal, it is not probable that this can be accomplished without major structural changes in state and local service delivery programs. Therefore, a move toward 211 systems in place throughout California would assist consumers in securing information about services. This would help them to become better self-advocates. That seems to be a more reasonable goal. (PSA 27) We live in a small, tightly knit community, with shared links, open coordination and collaboration, sharing. We share information regularly via quarterly meetings, community events, local media, gatherings, and local publications. This system reaches all levels of the senior community, from low to high income, central as well as rural residents. (PSA 24) One oversight entity; Create a base point for coordination of all services rather than

having the person have to move from one provider to the next. Services could all be provided through the cities; senior centers as focal points.



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More networking and collaboration will be necessary from providers and between County and providers. Maintain and expand the Office on Aging to be a one-stop call to access a case

manager or service coordinator that can set up an ongoing program of services as needed.

Appoint teams to arrange for delivering services in the most expeditious way. Close communication between service providers. All social service programs should have one access number – no wrong door. Continue to try to make city and county entities act as one collaborative. Get all agencies which serve seniors together in a collaborative, noncompetitive

environment to reduce duplication, to develop services which would be provided in phases to seniors, dependent on their level of need. Advocacy is needed in order to increase awareness of the need and benefits of

social services. Include suggestions from all quarters, but especially from consumers. To achieve this the paperwork and administrative systems will have to be simplified. Encourage more collaborative RFPs. (PSA 22)

Eliminate fragmentation in order to create one integrated system of care that is

seamless to the consumer (e.g. combining hotlines so consumer can call one hotline and get the referral they need);

Integrate multiple funding streams; Streamline eligibility criteria to allow seamless access to services and make it easy

to move from one program to another. Eliminate ‘silos’. (PSA 20)

This question is one that has been tasked to the Advisory Council as part of their work for FY06/07. It is expected that the Advisory Council will come up with some ideas that the K/T AAA staff will pursue. (PSA 15) The COA Advisory Council has started to meet with the Public Authority Advisory Board, realizing that they have similar concerns and issues that affect their client base and can accomplish more together than acting independently. (PSA 10) The Aging and Adult Services Division was created more than twenty years ago to provide comprehensive health and social services to San Mateo County’s adults with chronic health care problems. This unique division was created by bringing together individual adult services from the Social Services, Mental Health, and Coroner/public Guardian programs in the County to create a single, uniform countywide continuum of care for the chronically ill. The division provides a broad array of programs and services in the areas of advocacy, prevention, support and protection. The Centralized Intake Unit at Aging and Adult Services serves as a single point of entry for adults into the system of publicly provided services. A single point of intake makes the County’s adult services system more accessible, promotes more comprehensive, holistic assessments of elderly and adults with disabilities and strengthens the coordination among existing programs.



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The Centralized Intake Unit consists of a 24-hour telephone line (the TIES Line), an emergency response capability and a multidisciplinary team comprised of professionals with expertise in public health, mental health, substance use/misuse, and other related services. Staff has expertise in the areas of intake, assessment, and short-term case management. (PSA 8)

There was discussion of strengthening the senior centers and developing them to the largest degree possible as resource centers to older adults, particularly with a focus on meeting the needs of the baby boomer population. The Senior Centers were recognized at the public hearings as the point of entry for all services. Participants mentioned bringing more services to the Centers with the idea of “no wrong door”. (PSA 26)

Question #5 What administrative hurdles and barriers to change need to be overcome at both the state and county/local level? A major hurdle at the state and local level is the silo funding and narrow eligibility requirements that make providing community based services challenging. Allowing the funding to follow the client is an idea whose time has come for California. (PSA 1) Although accountability lies at the heart of every government program, many state and federal funding sources have abandoned the grassroots focus, which is the spirit of the OAA, and instead rely upon regulations, forms, and process to support program goals. (PSA 3) Lack of funding – funding from the state and federal levels for aging services have been stagnant and not kept up with the growing older adult population much less being adequate to prepare for Baby Boomers. (PSA 5) California’s Department of Health Services must have the capacity to work with local entities to provide Medicaid waivers for a variety of programs that allow individuals to remain independent for as long as possible and in the least restrictive environment. (PSA 6) Administrative hurdles and barriers to change occurring at both the state and local level include: Program “silos” and accompanying operational and reporting regulations and

statutes which support program segregation rather than collaboration. Funding mechanism is attached to programs rather than individuals.



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Policy, eligibility and reimbursement-based institutional biases that promote nursing home placements rather than home and community-based care.

Lack of consolidated administration at the State and Federal levels and consequently at the local level. Overlapping and duplicative regulatory requirements which result in wasted financial and staff resources.

Other barriers include: Lack of coordination between services Lack of focus on the consumer Limited financial resources and complex funding streams Inconsistent eligibility requirements Multiple reporting systems Out of date client processing and tracking systems Confidentiality issues in sharing client information Complex legislation and regulations Lack of cohesive leadership at the local, state and national levels on the issue Resistance to change due to vested interest in the status quo. (PSA 7)

The AAA in partnership with the for Every Generation movement has developed a Myth Busters Campaign to transform the public perceptions of aging, focusing on the positive aspects of the aging process while combating negative media images of older persons. As part of that campaign, the AAA runs “Myth Buster” articles on aging in its quarterly Senior Information Newsletter which has a circulation of over 20,000. (PSA 7) In order for us to make greater progress at the local level, we need state officials to pave the way by promoting flexibility and improving coordination within state agencies. (PSA 8) Aging services always run the risk of being buried in the bureaucracy of state and county government and branded as welfare programs thus losing their voice to advocate. (PSA 10) Administrative hurdles and barriers at the state and local levels include timeliness in the provision of guidelines and/or regulations, better understanding and communication between fiscal and program staff, and consistency in staff providing direction and guidance. (PSA 11) Client confidentiality including HIPAA varying intake and program requirements, funding silos and turf issues are just some of the challenges to creating a more seamless system. (PSA 13) While a standard of service is desirable, each PSA has a unique client base with fluctuating needs. Under Article 3, Section 7312 of the California Code of Regulations, AAAs allocate funds to comply with adequate proportion funding requirements for Title III B priority services. These priority services are classified under the categories of “Access,” “In-Home Services,” and “Legal Assistance Required Activities.” During the fiscal year, an AAA may determine that additional funds are needed, for example, for Home-Delivered Meals, a Title III C2 funded program, and that funds are available from



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the “Access” category of Title III B priority services. However, the transfer of Title III B funds may affect the minimum percentage allocations across Title III B priority service categories. Although AAAs can propose an adjustment of adequate proportion ratios for priority service categories at a public hearing, the time involved in this process may negatively impact the timeliness of service provision. Allowing AAAs greater flexibility in redirecting funding between priority service categories to services with the greatest need would enable a fine-tuned response to fluctuating service demands, and would give AAAs the ability to truly act outside the box. (PSA 14) A statewide review of data collection methodology, storage, and usage could be conducted to expand the focus from data processing to data mining. (PSA 14) The biggest hurdle that PSA 15 has in trying to integrate the new seniors with their older counterparts is funding. With the reduction of funds from the federal government and stable funding from the State, it is hard enough for the AAA to provide the services that the current clients require. Any additional research is generally placed near the bottom of the activities that are planned each year. (PSA 15) Hurdles and barriers include a demand for services and programs that outweighs available resources (not enough money and overworked staff) at the state and local levels; too much bureaucracy; and, sometimes a lack of understanding at the state level for the circumstances, issues, and obstacles that are unique to each county. There is a need for more communication, flexibility, and creativity at both levels. (PSA 18) Administratively among local service providers, there is fierce competition among community-based service providers for the same pots of funds; geographical and cultural obstacles among the providers; a lack of information and awareness of what different organizations are doing; and, among service providers and some local governments, there is a sense of territorialism and void of creativity that that prevents collaboration. (PSA 18) The hurdles and barriers are easier to identify than they are to solve. Currently, service categories and the funding streams supporting them operate in silos. In medical healthcare, public sector funding like Medi-Cal does not integrate with commercial insurance. The rules are different in terms of utilization parameters, compliance monitoring, claims processing, documentation, reporting, and the flow of communication is not interlinked between the Centers for Medicare and Medicaid Services and commercial benefit plans. Therefore, the third party payor system does not foster collaboration. At the provider level, there is a long history of poor coordination of care among the same overall category of service delivery, such as medicine. The effect is more profound when moving across types of service provision, such as mental health, housing, community, and medical. In the public sector, when different public sector departments provide for the same category of care, coordination is absent. In the County of Los Angeles, an elderly consumer could be seen for age-related problems by the department of health, social services, mental health, and the AAA, yet it’s conducted in silos and no coordination takes place. The issues among payor systems, the provision of service by care category, and across public sector departments are



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extremely complex, with procedural, regulatory, historical, and structural factors that would require massive overhaul to effect real change. Whatever solution is used at a local level can only be viewed as an approximation, because there simply isn’t the authority to enact such fundamental change in how systems operate separately. (PSA 19) The sheer size of PSA 20 is a barrier. San Bernardino County is the largest land

county in the nation. Implementing change to so many rural and diverse communities is complex and time consuming.

Breadth and complexity of aging issues; not only do we now have baby boomers but our aging our aging. The 85 and older groups is the fasting growing groups of seniors we have.

Succession planning-Administrative and support staff are continually retiring, promoting and leaving due to limited administrative dollars. This ‘revolving’ door phenomenon in staffing inhibits the development of well-trained staff to carry out the services. This leaves little time for implementing change or innovative thinking.

(PSA 20) For years, the County administration as a whole was hesitant and slow to accept change. The conservative viewpoint prevented growth, until recently. This change in attitude and openness to growth also brought with it a stronger spirit of cohesiveness. (PSA 24) Ageism – must change attitudes & public perception of aging Insufficient numbers of bilingual staff Few materials in different languages Misinformation Lack of awareness Leadership is lacking Denial Fear of change; lack of willingness to shift thinking in order to achieve goals Duplication of services Multiple administrative systems, databases, processes, applications (PSA 22)

State, county, and local level policy makers need to be educated regarding senior services. The challenges of service delivery and program funding for the senior population cannot be addressed the same way policies are developed for addressing children, youth and families. The longevity of the needs of the senior population is very much different. (PSA 25) State and federal funding restrictions that prohibit certain types of programming Variations in structures of local governments Smaller agencies do not have the benefit of larger infrastructure (as in county

governments, etc.) Extensive reporting requirements that require time that could be better spent on

program development (PSA 27)



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Untimely dissemination of information from government agencies creates difficulties for the AAA in meeting budget constraints, while staff turnover and the need for acceptance of innovative versus traditional services creates challenges in providing assistance to our client population. As with any government agency, the civil service practices are often cumbersome in meeting the challenges of an ever-changing work force, especially in good economic times. (PSA 33) At the state level interpretation of program regulations in meeting the needs of

consumers need to be consistent and be provided by individuals that have specific expertise.

Innovation in program development and interpretation needs to be welcomed and encouraged.

Government at all levels needs to realize that the face of aging is changing and core services need to adapt accordingly. This will involve assessing funding to meet the needs of the “baby boomers”. (PSA 31)

Low wages and lack of health benefits for care providers were listed at the public hearings as a barrier to quality home care for aged and disabled. (PSA 26) The state funding categories prohibit the creative use of funds to develop newer more innovative programs. Our service unit definitions are too narrow and it makes creating a better approach impossible. If, for example, I wanted to create a new program integrating community programs I think it would take 18 months or more to get the program approved. We evolve too slowly and we don’t give our community programs an opportunity to break away from that rigidity. (PSA 9) Under leadership and planning efforts of the Long Term Care Council, the State should provide the framework of minimum compliance parameters related to client tracking, consolidated reporting, integrated intake, etc., within which local Information Technology (IT) efforts could explore options that satisfy both local, state and federal needs. This could also include the application of shared ADL minimums across programs, and a mix of senior and adults with disabilities data. (PSA 21) Consistent and on-going education is needed for professionals in order that there is uniformity within and between, as to how programs are applied to individual customers with multiple needs. For example, individual interpretation of confidentiality issues are due in part to fears of legal repercussions and sanctions by professional licensing organizations as well as inconsistencies in regulatory requirements, interpretation, and licensing, i.e., Federal Privacy Act vis-à-vis using Social Security numbers in record keeping. (PSA 21) Question #6 How do we provide a leadership and advocacy role in the development of service system standards that are uniform and not dependent upon income?



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Change needs to occur at the federal and state levels. Local stakeholders need to identify the issues and organize advocacy to facilitate change at the federal and state levels. (PSA 1) PSA 2 will provide a leadership and advocacy role through active participation in the local community workgroups to insure systems of care are equal for low, moderate, and upper-income persons. (PSA 2) Assure that there is a diversity of participants on the AAA advisory councils. Make sure that all agencies and constituents concerned are at the table to develop

system standards. Implement the recommendations of commissions formed to study these issues such

as the recommendation to create a state level department of adult and aging services to encompass all the funding streams and programs affecting this population. This will increase the ability to provide the same services to all. (PSA 5)

We must continue to make policy-makers aware of the dichotomies inherent to the structures of our current systems of care. Private-pay models are driven by market forces and allow for more flexibility in services in order to respond to the needs or demands of consumers, while public programs find themselves increasingly hamstrung by regulation and reporting requirements that can unintentionally stand in the way of responding to consumers’ true needs. (PSA 6) The Planning Committee commented that this is inevitable in a capitalistic democracy; there are numerous examples including pre-school opportunities, the education system at all levels, health care system, city and state governments with varying tax bases, salaries and benefit packages offered at corporations depending on success and philosophy, etc. (PSA 10) Changes of this magnitude will require a major federal and state commitment to overhaul the existing system. For example, such a system would necessarily require universal health care as a starting point. Housing, land use/planning and transportation are other examples. Abolishing income status as a criteria for providing services is not realistic given financial realities. (PSA 13) Establish a standard statewide report card program for seniors to rate services and require a minimum overall satisfaction rating in key service indicators for all service providers. As part of the monitoring process, set up a statewide “mystery-client” program whereby volunteers pose as clients at different income levels, apply for services, and provide a report on their experience. Share the report results with the appropriate PSA, who would then disseminate the information to the service provider. (PSA 14) Consumers and community-oriented advocacy organizations need to take more

responsibility for getting involved in urban and regional planning for the purpose of educating decision makers regarding senior service needs. Educate seniors and senior advisory council members on how to be their own best advocates.



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Continue collaborations such as the Aging and Adult Collaboration in order to provide leadership and advocacy for seniors.

Assist in developing statewide and county level comprehensive databases of senior systems of care and standards. (PSA 20)

We are a poor County with a large percentage of low to moderately income individuals. Low to moderate-income individuals are familiar with the system of services. We need to target the rest of the population via social events, political events, and the media. This will help to round out our local network to include all levels and representation of the senior population. (PSA 24) Seek grant opportunities Combine funding at the local level Link with community partners Community Action Networks to activate the communities to design services that

meet their local needs Identify legislative changes that will allow easier access to staff (PSA 23)

The Department of Aging conducts a wide range of conferences and seminars for caregivers to educate them on services available to them as caregivers and to expose the senior population to Senior Multipurpose Centers (MPC) where senior services can be accessed. The conferences and seminars are designed to not exclude anyone and easily be accessed by everyone. The Los Angeles City Department On Aging’s leadership and advocacy role in the development of a comprehensive service system lies in the development of innovative programs, (i.e. Research on Effective Exercise Interventions for Preventing Older Adult Falls and the Physical Activity Demonstration Program), collaborations (i.e., LA Access to Benefits Coalition), and seeking funds from sources outside of the normal funding stream, (i.e. Centers for Disease Control and Prevention) and the creation of a foundation whose primary purpose is generating funds for senior services without self-imposed restrictions. Furthermore, we believe that a strategy that seeks to diversify funding sources and values partnerships will provide a seamless system to all in need regardless of their income. (PSA 25) As a leader in the community, the AAA can promote the development of service system standards that are uniform and not dependent upon income through existing association meetings, advisory councils, key stakeholders, etc. (PSA 27) That will only occur when we, as a society, place equal value on all our residents and are prepared to fund a seamless service delivery system. We need to look to other States in the U.S. and other countries with existing seamless services for their expertise. (PSA 32) Question #7 How do we assure quality standards are maintained or developed across services regardless of the funding source and/or the service provider?



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Standardized monitoring tools assist with the quality of programs regardless of funding for services. For many programs this works across the state and could be expanded to maintain standards across multiple programs. (PSA 1) The tool to measure quality standards will be developed by the local community workgroups. (PSA 2) San Francisco’s Living With Dignity Strategic Plan dictates the formation of a Quality Standards Workgroup. It is anticipated that this workgroup will be formed later in 2006 or early in 2007. (PSA 6) Commission On Aging is implementing a uniform intake and assessment process that is web based and accessible to case managers, hospital discharge planners, IHSS and APS social workers, and potentially in the future to home health agencies and pharmacists. (PSA 10) Clearly, testing of any new service delivery standards would be necessary before making any changes. A key challenge will be to create monitoring standards that do not become so burdensome that they interfere with effective service delivery. (PSA 13) Provide adequate funding/staff to enforce the standards of care that are required by

the Federal nursing home reform law. Establish uniform standards for admission agreements that ensure language is clear

and readable, not using legal terminology, and provides full disclosure of services and fees.

Expand opportunities for engaging seniors and set standards for effective training and supervision of volunteers.

Ensure that all HIPAA/privacy standards are met and enforced. Assist the State and other aging providers in working Work with UC and CSU

system to explore the need for Gerontology Centers of Excellence in the Southern California.

Assist in developing statewide and county level comprehensive databases of senior systems of care and standards.

Assist State in developing standardized program and fiscal monitoring tools on Aging programs. This would provide more consistency in service expectations and delivery. (PSA 20)

We can utilize survey procedures, monitor provider services, continually update and revise the community resource handbooks, increase follow-up contacts with clients, continued information sharing via monthly provider/case management meetings, coordination with other service groups within the County sharing resources. In sharing information with this type of network, we can also share new service delivery methods used by other agencies, and utilize these methods, modifying and incorporating them into our own systems, rather than reinventing the wheel or making the same mistakes. (PSA 24)



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Customer feedback is always important. Every customer needs a chance to comment.

Customer satisfaction is the only way to measure quality. Have an ombudsman to interact with providers and consumers Have a quality management team in place to oversee and monitor standards Outcome measurements by use of client satisfaction surveys Trainings Testing service delivery methods (pilot programs) Self-monitoring of agencies Remove communication barriers between agencies – review regularly to evaluate

how agencies are doing Appropriate and consistent monitoring by professionals, including consequences for

violations. (PSA 22) The DOA has regularly scheduled meetings with its service providers (Policy Development Task Force [PDTF]). The meetings allow the Los Angeles City Department On Aging (DOA) to discuss changes in policy overseeing the delivery of services and allocation of funding prior to implementation. The PDTF meetings also provide contractors the opportunity to comment on City and DOA policy regarding the delivery of services and funding, and address issues that may arise as a result of those policies. PSA 25 also enlists the aid of its advisory board to monitor the quality of service delivery and elicit feedback from seniors to the extent it can be determined the needs of seniors are being met. The DOA also conducts 5 Public Hearings throughout the City every year in which service providers (contracted and non-contracted) and seniors are invited to comment on the PSA’s Area Plan for the provision of services. The governing board that consists of 15 Council Members discusses and approves the Area Plan as to its content. In addition, our Program Development Division has begun to develop best protocols for our care management and Adult Day Services programs. (PSA 25) The results of several challenge grants funded by the California Department of Aging (CDA) could have been used to effect policy changes and potential system redesign at the state level which would obtain maximum leverage from these funds over time. PSA 21) Conclusion/Recommendation The AAAs have made an impressive start to addressing integration of services for the elderly and adults with disabilities populations. Many AAAs have already concluded that with limited resources within the AAA and the community, they must coordinate with local agencies to serve these populations in the most resourceful means possible. The AAAs are also looking to future technology to assist their clients to receive services in a more efficient manner. This connection to the world of computers, the internet and other technologies will also provide a connection between the



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elderly/adults with disabilities and the younger generations who have already accepted new technology are part of their daily lives.



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California Department of Aging Planning for the Baby ... · PDF fileCalifornia Department of Aging Planning for the Baby Boomers Report: Integration of Service Systems Introduction

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